Biologicals

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
cytomegalovirus immune globuln CYTOGAM VIAL    
hepatitis B immun glob/maltose HEPAGAM B VIAL    
hepatitis B immune globulin HYPERHEP B S-D SYRINGE    
hepatitis B immune globulin NABI-HB VIAL    
hepatitis B immune globulin HYPERHEP B S-D VIAL    
immun glob G(IgG)/gly/IgA 0-50 GAMMAPLEX VIAL    
lymphocyte IG, antithymocyte ATGAM AMPUL    
lymphocyte immune glob,rabbit THYMOGLOBULIN VIAL    
rabies immune globulin/PF HYPERRAB S-D VIAL    
Rho(D) immune globulin MICRHOGAM ULTRA-FILTERED PLUS SYRINGE    
Rho(D) immune globulin RHOGAM ULTRA-FILTERED PLUS SYRINGE    
Rho(D) immune globulin RHOPHYLAC SYRINGE    
Rho(D) immune globulin HYPERRHO S-D SYRINGE    
Rho(D) immune globulin/maltose WINRHO SDF VIAL    
tetanus immune globulin/PF HYPERTET S-D SYRINGE    
tuberculin,purif.prot.deriv. APLISOL VIAL    
varicella-zoster Ig/maltose VARIZIG VIAL